Patients with limited health literacy carry a disproportionate burden of disease; many have difficulty understanding and remembering medication dosing schedules. A number of studies have evaluated the delivery of medication prompts via text messaging using SMS (Short Message Service); however these messages are of limited value for delivering medication prompts to patients with literacy issues as they can only contain text. Solution: Pictographic medication instructions may be sent to cell phones using a new messaging service called MMS (Multimedia Messaging Service) that allows images, text, and audio to be 'pushed' to the recipient. These messages may help serve as cues to action and the format may be more usable for people with low health literacy and limited English proficiency than simple text messages. Purpose: The immediate goal of this project is to develop a set of valid and reliable medication-related pictographs that can be delivered via cell phones to patients with limited health literacy using a new mode of text messages that supports images. We will test these pictographs in a laboratory setting with a sample of patients from the target population. Methods: We will use focus groups to help guide the development of an initial bank of pictographs. Laboratory testing in our second aim will reduce competing variants of pictographs, establish content validity and reliability, and allow for exploration of additional enhancements such as voice assisted pictographs. Within our third aim we will conduct usability tests as we simulate the delivery of pictographic medication reminders to determine the overall feasibility and safety of our intervention. Analysis: Focus group data will be transcribed and independently coded by two researchers for thematic content. Pictographs with multiple variants will be discerned using the Friedman's two-way analysis of variance by ranks. Individual usability tests will be analyzed with a combination of qualitative and quantitative approaches. Conclusion: We expect that these results will establish the structures and processes necessary for demonstrating outcomes in a randomized, controlled, clinical trial. PUBLIC HEALTH RELEVANCE: Working with participants with low health literacy, we will develop an initial bank of medication related pictographs that are optimized to be delivered on cell phones as medication reminders. We will then test these in a laboratory setting to establish validity and reliability. We will also conduct usability testing with participants and a diverse range of mobile handsets. The results will establish the structures and processes necessary for a randomized controlled clinical trial.